Hampton Sylvie
Nurs Times. 2015;111(48):16-9.
This article, part 4 in a series on wound management, addresses the sometimes routine yet crucial task of documentation. Clear and accurate records of a wound enable its progress to be determined so the appropriate treatment can be applied. Thorough records mean any practitioner picking up a patient's notes will know when the wound was last checked, how it looked and what dressing and/or treatment was applied, ensuring continuity of care. Documenting every assessment also has legal implications, demonstrating due consideration and care of the patient and the rationale for any treatment carried out. Part 5 in the series discusses wound dressing characteristics and selection.
本文是伤口处理系列文章的第4部分，讨论了有时看似常规却至关重要的记录工作。对伤口进行清晰、准确的记录，有助于确定其进展情况，从而能够采取适当的治疗措施。详尽的记录意味着任何查看患者病历的医护人员都能了解伤口上次检查的时间、外观以及所使用的敷料和/或治疗方法，确保护理工作的连续性。记录每次评估情况还具有法律意义，能证明对患者给予了充分的考虑和护理，以及实施任何治疗的依据。本系列的第5部分将讨论伤口敷料的特性和选择。
